Health inspection·March 22, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure personal privacy during personal care for 1 of 5 resident (Resident #1) observed for personal privacy in that: Residents Affected - Few While performing the incontinent care for Resident #1, CNA A and CNA B did not ensure Resident #1's personal privacy. This deficient practice could affect residents and could result in loss of dignity and low self-esteem. The findings were: Record review of Resident #1's face sheet, dated 3/20/24, Resident #1 was admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy [shrinking of muscle or nerve tissue], not elsewhere classified, multiple sites, unspecified speech disturbances, history of falling, and cognitive communication deficit [difficulty communicating due to injury to the brain]. Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1's BIMS score was 6, signifying severe cognitive impairment. Observation on 3/19/24 at 1:39 p.m. revealed CNA A and CNA B entered Resident #1's room. At 1:44 p.m., Resident #1's roommate, Resident #4, went to the restroom inside their (Resident #1's and Resident #4's) room. At 1:45 p.m., CNA A and CNA B pulled Resident #1's privacy curtain most of the way, but left an opening in the curtain. CNA A and CNA B then began Resident #1's incontinent care. At 1:49 p.m., while Resident #1's perineal area was uncovered and the staff were still performing Resident #1's incontinent care, Resident #4 exited the bathroom and walked passed the opening in the curtains. During a joint interview on 3/19/24 at 1:56 p.m., CNA A confirmed Resident #1's privacy curtain was open during Resident #1's incontinent care. CNA B confirmed the privacy curtain should have been completely closed. CNA B stated it was important to close the curtain for the purposes of privacy and stated she did notice with Resident #4 walked passed the opening in the privacy curtain during Resident #1's incontinent care. During an interview on 3/22/24 at 11:15 a.m., when asked if the facility had a quality assurance process for privacy, the DON stated, In-servicing everybody on the rights of the resident to privacy and we have that on [the facility's online education portal] in our resident rights. We do a lot of in-service huddles with the staff. And some of those are randomly when we're rounding or if the Page 1 of 6 676158 676158 03/22/2024 Sonterra Health Center 18514 Sonterra Place San Antonio, TX 78258

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few patient complains about something. When asked what sort of negative effects could occur to the resident if privacy was not assured, the DON stated, it's dignity. It's not just physical and psychological dignity that we're here to protect and we're advocating for them. Record review of a facility policy titled, Resident Rights, not dated, revealed the following verbiage: [The residents] will also have the right to privacy, maintain privacy curtains for dressing and when providing care. 676158 Page 2 of 6 676158 03/22/2024 Sonterra Health Center 18514 Sonterra Place San Antonio, TX 78258

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 4 residents (Resident #2) reviewed for storage of drugs. LVN C left Resident #2's morning medications at bedside. This deficient practice could place residents at risk of medication misuse and diversion. The findings were: Record review of Resident #2's face sheet, dated 3/20/24, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of acute pulmonary edema [excess fluid in the lungs], chronic kidney disease, stage 3 unspecified, history of falling, and presence of cardiac pacemaker [a device that regular's the heart's beat]. Record review of Resident #2's BIMs score, dated 3/19/24, revealed Resident #2 had a BIMS score of 15, signifying no cognitive impairment. Record review of Resident #2's physician orders, dated 3/20/24, revealed the following medications: - Protonix [a medication used to acid reflux disease] Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth in the morning. This order was dated 3/18/24. - HumaLOG [a type of injectable, fast-acting medication that helps control high blood sugar levels] Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale. This order was dated 3/18/24. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) [a medication to make breathing easier] 1 application inhale orally via nebulizer four times a day. This order was dated 3/19/24. Observation on 3/20/24 at 6:23 a.m. revealed LVN C prepared Resident #2's morning medications: one Protonix pill, insulin Humalog pen, and one ipratropium-albuterol nebulizer dose. LVN C entered Resident #2's room and placed the three medications on Resident #2's bedside table. LVN C realized she did not bring a cup of water for Resident #2's Protonix pill and left the medications on Resident #2's bedside table to obtain a cup of water. LVN C returned with a cup of water and administered Resident #2's three morning medications. During an interview on 3/20/24 at 6:39 a.m., when asked how she made sure medications were secured, LVN C stated, by reading the expiration dates, the right dose, the right patient. Making sure the time, like the insulin we write when we open it. LVN C stated medications were left in the resident room and she should have brought Resident #2's medications with her when she went to get water for 676158 Page 3 of 6 676158 03/22/2024 Sonterra Health Center 18514 Sonterra Place San Antonio, TX 78258

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #2. LVN C stated it was important to make sure medications were not left in the resident room so the resident did not take the medications or take the medications in a different route. During an interview on 3/22/24 at 11:15 a.m., the DON stated the facility had a policy to ensure medications were stored in a box that was locked. When asked what sort of negative effects could occur to the residents if medications were left unsecured, the DON stated, it can be a simple effect, it can be a huge effect. Whatever it is we have to make sure the medication is secured. Record review of a facility policy titled, Medication Access and Storage, not dated, revealed the following: medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 676158 Page 4 of 6 676158 03/22/2024 Sonterra Health Center 18514 Sonterra Place San Antonio, TX 78258

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #3) reviewed for accuracy of medical records in that: CNA D documented she gave Resident #3's clonazepam (a medication for seizures) on 2/20/24, which was after Resident #3 ran out of clonazepam on 2/19/24 and before the medication was restocked on 2/22/24. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings were: Record review of Resident #3's face sheet, dated 3/19/24, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of cerebral palsy [a disorder that affects a person's ability to move and maintain balance and posture], unspecified, dysphagia [difficulty swallowing], unspecified, weakness, unspecified convulsions, and muscle weakness (generalized.) Record review of Resident #3's physician orders, dated 3/19/24, revealed the following order dated 12/28/23: clonazePAM Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth two times a day. Record review of Resident #3's February 2024 MAR and TAR, obtained on 3/19/24, revealed the following documentation on Resident #3's clonazepam on the following days: - On 2/19/24, 7 was documented for both the morning and evening dose. - On 2/20/24, 7 was documented for the morning. The dose was documented with a checkmark on the evening dose. - On 2/21/24, 7 was documented for the morning and evening dose. Further record review of Resident #3's February 2024 MAR and TAR revealed, 7=Other / See Nurse Notes. Record review of Resident #3's nursing progress notes from 2/1/24 to 3/20/24, obtained on 3/20/24, revealed the following: - Progress Note written on 2/19/24 11:05 a.m. by CMA E, revealed: Note Text : clonazePAM Oral Tablet 0.5 MG Give 1 tablet by mouth two times a day related to UNSPECIFIED CONVULSIONS. There was no further documentation to clarify what happened during this medication administration or if there were any supply issues. - Progress Note written on 2/19/24 at 8:52 p.m. by CMA D, revealed: Note Text : clonazePAM Oral Tablet 0.5 MG Give 1 tablet by mouth two times a day related to UNSPECIFIED CONVULSIONS . on order. 676158 Page 5 of 6 676158 03/22/2024 Sonterra Health Center 18514 Sonterra Place San Antonio, TX 78258

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Progress Note written on 2/20/24 at 7:43 a.m. by CMA E revealed: Note Text : clonazePAM Oral Tablet 0.5 MG Give 1 tablet by mouth two times a day related to UNSPECIFIED CONVULSIONS. There was no further documentation to clarify what happened during this medication administration or if there were any supply issues. - Progress Note written on 2/21/24 at 7:35 a.m. by CMA E revealed: Give 1 tablet by mouth two times a day related to UNSPECIFIED CONVULSIONS. There was no further documentation to clarify what happened during this medication administration or if there were any supply issues. - Progress Note written on 2/21/24 at 7:45 p.m. by CMA D revealed: Note Text : clonazePAM Oral Tablet 0.5 MG Give 1 tablet by mouth two times a day related to UNSPECIFIED CONVULSIONS . on order. During an interview on 3/20/24 at 9:05 a.m., CMA E stated she would normally re-order medications once a resident had about 8-7 doses left of the medication. CMA E stated she recalled Resident #3 did not have her clonazepam medication for a few days, and could not recall the specific dates when Resident #3 did not receive her medication. CMA E stated the first day Resident #3 did not receive her clonazepam, she reported the issue to the nurse on schedule at the time, which was an agency nurse whose name she could not recall. CMA E stated only a nurse could order the clonazepam and she did not know what was the cause of the delay in obtaining the medication supply. CMA E stated she notified the ADON and DON about the issue. During an interview on 3/20/24 at 10:27 a.m., CMA D stated she usually reordered medication when the resident had about one week supply left. CMA D stated she recalled Resident #3 did not have her medication for a little bit and could not recall which specific dates Resident #3 ran out of her medication. CMA D stated she believed there might have been an issue with Resident #3's insurance. CMA D stated she mistakenly documented she gave Resident #3's medications on 2/20/24. CMA D confirmed she should not checking off medications in the MAR as administered when she did not actually administer the medication. During an interview on 3/22/24 at 11:15 a.m., the DON stated the staff document medication administration after the resident received the medication. The DON stated a checkmark on the Medication Administration Record meant that the medication was given, an x meant the medication was not due, but she was not sure what 7 meant. The DON stated when the resident did not receive the medication, then the staff must document the reason. The DON stated if the medication was not given because of an issue with supply, it should be documented in the electronic medical record. The DON stated she was not aware of any issues with Resident #3's medications in February 2023. When asked if the facility had a quality assurance process that ensured accurate documentation of medication administration, the DON stated the facility had in-services on medication administration and the facility reviewed their 24-hour report. Record review of a facility policy titled, Administration of Drugs, not dated, revealed the following: should a drug be withheld, refused, or given other than at the scheduled time, the nurse must note it in the MAR for that particular drug. 676158 Page 6 of 6